Sleep disorders in hyperactive children
Sleep disorders in hyperactive children
“Everyone has attention deficits or restlessness occasionally. People with ADHD have them every day and all day.”
GENERAL ASPECTS
Attention-deficit/hyperactivity disorder (ADHD) is characterized by a persistent pattern of inattention (distractions, disorganization, time management problems, forgetfulness, etc.), hyperactivity (difficulty remaining still, restlessness, nervousness, excessive talking, etc.) and/or impulsivity (disregarding turns, interrupting conversations, making hasty decisions), which interferes with functioning and development. ADHD is a major public health problem in our society today, being the most frequent cause of conduct disorder in childhood-adolescence.
Although most of these manifestations are usually associated, there is also an “inattentive subtype” and a “hyperactive/impulsive subtype.
It is important to know that ADHD is a chronic disorder, which may persist into adulthood, and that treatment should include pharmacological and non-pharmacological measures.
TDAH-SLEEP/SLEEP-TDAH RELATIONSHIP
The relationship between sleep and attention deficit hyperactivity disorder (ADHD) has been known for decades and this interrelationship is complex, multifactorial and multidirectional.
Complaints of sleep problems in children with ADHD are not uncommon and appear in up to 55% of cases, although, unfortunately, this relationship has sometimes been ignored or minimized. On the other hand, we know that children with sleep disturbances, with inadequate or poor quality sleep, also develop ADHD-like symptoms (Fig. 1).
Figure 1. Model of the multifactorial and multidirectional relationship between ADHD and sleep disorders. (adapted from Pediatría Integral 2014; XVIII (9): 668-677).
When analyzing how children diagnosed with ADHD sleep, 5 subtypes of sleep disorders have been found:
- Circadian rhythm disturbances (delayed melatonin secretion and insomnia of conciliation). Sometimes there is a delay in the onset of nocturnal melatonin secretion, without a delay in the end of melatonin secretion, so that the child’s biological night is shorter.
- Obstructive sleep apneas, with snoring and, in many occasions, associated with adenotonsillar hypertrophy.
- Periodic limb movements and restless legs syndrome or RLS (characterized by a need to move the legs, associated or not with discomfort, which appears at rest and at the end of the day, and improves when moving them). These symptoms are 10 times more frequent in children with ADHD.
- Sleep fragmentation due to epileptiform discharges or epileptic seizures.
- Daytime hypersomnolence (excessive tendency to fall asleep in different situations, prolonged naps in children over 5 years old, etc.).
Beyond this classification, globally, children with ADHD present chronic sleep deprivation that should be evaluated as a possible unifying marker of ADHD.
Given the extent of daytime and nighttime manifestations associated with ADHD, it is clear that it should be conceptualized as a “24-hour disorder”. Therefore, collecting information on possible sleep disorders should be part of the evaluation of every child/adolescent with behavioral and/or academic problems, especially in those diagnosed with or suspected of having ADHD.
DIAGNOSTIC EVALUATION
The evaluation should be based on an adequate medical history elaborated by the physician together with different questionnaires or specific scales filled out by the parents. It is advisable that these questionnaires be accompanied by a sleep diary or diary, reflecting sleep episodes, awakenings and other events.
In some cases, depending on the results obtained from the clinical history, sleep diary and questionnaires, it is necessary to perform diagnostic tests to obtain the maximum diagnostic yield:
Actigraphy: validated device, with a sensor (accelerometer) placed on the wrist or ankle, which records muscle activity to differentiate between rest and movement phases. In recent years, other devices have become available that also record pulse, position or exposure to light. Actigraphy makes it possible to evaluate the duration of sleep, sleep episode times, the time it takes the child to fall asleep, periodic limb movements or nocturnal awakenings.
Pulse oximetry: this device allows the recording of O2 saturation through a sensor placed on the finger or foot, in order to assess whether there is oxygen desaturation in probable relation to a sleep-related breathing disorder (SRD).
Polysomnography (PSG): is the standardized recording of wakefulness and sleep states by synchronized monitoring of brain activity, muscle tone and eye movements along with other biological variables (for the diagnosis of respiratory, cardiac or motor events). Through PSG studies, it has been shown that 24% of children with ADHD have obstructive apneas and 30% have periodic leg movements during sleep. It also allows the recording of other nocturnal episodes such as sleepwalking.
Multiple Sleep Latencies Test (MSLT): excessive daytime sleepiness should be confirmed by this test, which is performed similarly to the PSG, during the morning and afternoon (5 tests of about 20 minutes, at 2-hour intervals), although it is difficult to perform in children under 8 years of age. The propensity to sleep is regulated by circadian rhythm and homeostatic need (internal stability), but in children, it is not manifested by yawning, but by behavioral disturbances, inattention and/or restlessness.
Cardio-respiratory polygraphy (CRP): when there is a suspicion of sleep apneas or a nocturnal breathing disorder, a home CRP can be performed, which evaluates only: naso-buccal flow, thoracic and/or abdominal respiratory effort, oxygen saturation (pulse oximetry), body position, snoring and heart rate. Patients with associated comorbidity or questionable results should have a complete PSG performed.
TREATMENT
The treatment of sleep disorders must be individualized for each child and each disorder. As a general rule, it is necessary (but not sufficient) to establish sleep hygiene rules.
- Maintain a regular schedule.
- Performing relaxing activities before going to bed
- Take care of the environment (adequate temperature, ventilated room, etc.).
- Exercise regularly, avoiding late afternoon.
- TV and books: avoid stories or movies with suspense, violence, dramas or horror.
- Avoid stimulants that make it difficult to initiate or maintain sleep (coffee, tea, chocolate, energy drinks, tobacco).
- Avoid using devices with illuminated screens 2-3 hours before going to bed.
- Do not have a late dinner or heavy meals.
- The bed is only for sleeping (it is not a place to study, play video games, check cell phone messages, eat, etc.).
- If the child cannot sleep, he/she should not stay in bed. It is preferable to get up and do some relaxing activity out of bed.
Table 1. Sleep hygiene standards in children.
Specialists
Meet our extensive team
What are we dealing with?
Specialized professionals
Request an appointment
Contact us
